CRITERIA FOR PATIENTS AT RISK IN RELATION TO MULTIORGANIC DEFICIENCY DUE TO BURN INJURIES

Yonov Y., Petkov P., Serdev N.

N.I. Pirogov Emergency Institute, Sofia, Bulgaria

SUMMARY. A prospective study was made of 700 burned patients treated at the Clinic of Thermal Trauma in the N.I. Pirogov Institute, Sofia, over a 34-month period. Of these, 140 presented moderately heavy and heavy Burns. Multiple organ failure (MOF) syndrome was found in 61 cases (43.57%). The criteria for assessing single-organ failure were those adopted in world practice. If at least two organ functions proved to be critically disturbed we considered that the patients had MOF syndrome. Patients with MOF were divided into two groups: Group A (recovered - 15 patients) and Group B (deceased - 46 patients). A third control group (Group C) comprised 20 patients with Burns of similar gravity, without MOF, all of whom recovered. A statistical analysis was performed. The contingent at risk for development of MOF consisted of: 1) male patients up to 50 years old and female patients over that age; 2) patients with burns of the upper airways, Burns in over 30% TBSA, and deep burns in over 10% TBSA; and 3) patients who developed sepsis or pneumonia.

The notion of "sequential system failure" as a synonym of "multiple organ failure" (M017) was introduced by Baue in 1975. Previous reports on post-operative organ deficiency treated each organ system as an isolated unit. Later studies established that multiple deficiency was observed more often than single-organ failure and that its onset was either sudden or gradual.
Since the beginning of the 1970s emergency medicine has been considered to be an independent discipline, and researchers have started to analyse the prognoses of different trauma outcomes. The probable course and outcome of the disease mainly depend on the following factors:

• total burn area
• surface area of full-thickness burns
• localization of Burns
• age of patient
• time interval between moment of accident and initiation of care

In all the patients in the series there was a time lapse of 30 ± 5 min prior to commencement of care. The more serious the trauma, the greater was the probability of the development of MOF. It was found that, in similar types of burn, some patients recovered while others developed MOF and either only survived with difficulty or died.
The aim of the present study was to establish what factors, in association with the severity of burns, led to the development of the MOF syndrome, and to determine the groups of patients at risk. A number of tasks were accomplished in order to achieve this aim: a prospective study of the largest possible contingent of moderately severe and severe burns, together with an analysis of cases in which MOF developed, plus a study of organic complications in burn patients that could be regarded as risk factors for the development of M0F.

Materials and methods

A prospective study was made of all Burn patients (700) admitted to the Clinic of Thermal Trauma at the N.I. Pirogov Institute, Sofia, in a 34-month period. The diagnosis of organ failure was based on pathophysiological data in accordance with universally recognized medical criteria.
Cases of two or more organ deficiencies were defined as multiple organ failure syndrome.
We analysed deficiencies in eight functional systems of vital importance: 1. respiratory system; 2. cardiovascular system; 3. secretory system; 4. gastrointestinal system; 5. liver system; 6. endocrine system; 7. haematopoietic system; 8. immune system and central nerve system following deficiency of liver detoxification function.
Treatment followed the therapeutic scheme adopted at our Clinic. Surgical interventions were performed after spontaneous or accelerated elimination of necroses through chemical or enzyme necrectorny or partial blood necrectomy. A control group of twenty patients was observed, consisting of cases of burns of similar severity that did not develop the MOF syndrome. Twenty supplementary factors were analysed that had some relation to the development of MOF, such as factors linked to the course of the disease (e.g., onset of organic deficiencies and bacteriological complications).
The data were processed using the W.J. Dixon Biomedical Computer Programs, 1989, University of California.

Results

Over a period of almost three years (1 January 198730 October 1989), we observed 140 patients out of a total intake of 700. Eight patients entering the Clinic presented moderately severe and severe Burn shock; 61 (43.6%) developed the MOF syndrome. The control group of patients who did not develop MOF consisted of 20 persons.
Table I presents the general characteristics of the burn trauma. The time preceding commencement of care, as a constant value, does not appear to be of importance for the outcome. For all patients, the time lapse varied between 30 and 35 min as patients were transported only from the outskirts of the city of Sofia. In these patients the severity of the burn was of substantial importance for the onset of the MOF syndrome.

Table II shows the frequency of the different types of deficiencies in the course of the disease, and Table III presents the complications due to nosological reasons. There was a very strong correlative dependence (r > 0.91) between the complications of sepsis, pneumonia and Curling's ulcer and the appearance of more than one function deficiency. Infectious and inflammatory complications were thus a risk factor for the appearance.of the MOF syndrome. The clinical manifestation of stress ulcers was a possible alternative to the development of M017, and in this case the reason was acute anaemia and the appearance of hypoxaemia combined with hypoxia.

The degree of deficiency, the rapidity and order of appearance, and the response to medication were also important factors. In our previous studies we established that in burns of up to 45% TBSA the endocrine system reacts adequately by increasing hormone secretion. When burns exceed 45% TBSA, an uncoordinated secretion of adaptive hormones continues until complete exhaustion.
The observation of immune reaction in cases of moderately severe and severe burns indicates a tendency for low immune reactions around day 3 in the three groups (the control group remained within the range of the reference values). In Group B this trend persevered until the fatal outcome. In Group A patients the low immune reactions started after day 3, attaining reference values around day 5-6. We have found in our studies that the vigour of immunity and the possibility of its quick restoration depend not only on the trauma severity but also on specific immunological features for each nation. The speedy restoration of immunity is an excellent guarantee against infectious complications (Fig. 1). Our clinical material is here rather limited as this report is intended to be a preliminary contribution.

Fig. 1 - Immunity changes.

Conclusion

The following groups of patients may be considered to be exposed to the risk of N1OF syndrome:

• patients with severe burns (heavy shock)
• patients with complications of bacterial infections (sepsis or pneumonia)
• patients with clinically manifested gastric or duodenal stress ulcers

RESUME. Les Auteurs ont effectué une étude prospective sur 700 patients brûlés traités à la Clinique des Traumatismes Thermales de lInstitut N.1. Pirogov pendant une période de 34 mois. De ces patients, 140 présentaient des brûlures modérément graves et graves. Le syndrome de l'insuffisance organique multiple (IOM) a été trouvé dans 61 cas (43,57%). Les critères pour diagnostiquer l'insuffisance d'un seul organe étaient les mêmes critères de la nonne internationale. Si au moins deux fonctions organiques étaient critiquement atteintes, les Auteurs ont exprimé une évaluation de 10M. Les patients atteints de IOM ont été divisé en deux groupes: le groupe A (guéris - 15 patients) et le groupe B (décédés - 46 patients). Un troisième groupe témoin (groupe C) contenait 20 patients atteints de brûlures de gravité comparable, mais sans 10M, qui se sont tous rétablis. L'analyse statistique a indiqué que les patients les plus exposés au risque de IOM étaient: 1) les patients de sexe masculin âgés jusqu'à 50 ans et les patients de sexe fémin âgés plus de 50 ans; 2) les patients atteints de brûlures des voies aériennes supérieures, de brûlures dans plus de 30% de la surface corporelle, et de brûlures profondes en plus de 10% de la surface corporelle; et 3) les patients qui ont présenté la sepsis ou la pneumonie.

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